434415496-12-20-2019-07-CC-MSEA-BLFVX5-20200203154854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415496
Report Date: 12/19/2019
Date Signed: 12/20/2019 10:25:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2019 and conducted by Evaluator Elizabeth Berumen

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20191217113316

FACILITY NAME:	SJB-KENNEDY CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	434415496
ADMINISTRATOR:	MELISSA LEZA		FACILITY TYPE:	850
ADDRESS:	1602 LUCRETIA AVENUE		TELEPHONE:	(408) 414-2700
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	60	CENSUS: 38	DATE:	12/19/2019
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jessica Mejia		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility didn't report incidents to Community Care Licensing (CCL)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Elizabeth Berumen, conducted a complaint inspection to the Facility. LPA met with Site Director, Jessica Mejia, and explained the nature of today's inspection to her. LPA interviewed Jessica Mejia and staff today, 12/19/19.
In investigating the allegation noted above, LPA became aware that there was an incident in which a preschool child stuck a bead in his nose. The child did sustain an injury as a result of the incident which required medical attention. The Facility failed to file an Unusual Injury report with the Department as required per Title 22 regulations.

Based on LPA's observations and interviews which were conducted and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC. 9099D.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL BE POSTED FOR 30 DAYS.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20191217113316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SJB-KENNEDY CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434415496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/20/2019 Section Cited CCR 101212(d)(1)(B)	1 2 3 4 5 6 7	101212(d) Reporting Requirements: Upon the occurrence, during the operation of the child care center of any of the events specified [...] a report shall be made to the Department [...] In addition, a written report containing the information [...] shall be submitted to the Department [...]. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director completed an unusual incident report today and provided the report to LPA. Site Director agrees to submit a written plan stating she understands the reporting requirements.
	8 9 10 11 12 13 14	Per LPA's inspection, Site Director became aware that a child obtained medical treatment after having a bead stuck in nose from bead activity at the center. The center failed to report the incident to CCL within the required time frame. This poses a potential heath and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019

LIC9099 (FAS) - (06/04)

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